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Re-directing nanomedicines to the spleen: A potential technology for peripheral immunomodulation. J Control Release 2022; 350:60-79. [DOI: 10.1016/j.jconrel.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 04/04/2022] [Accepted: 04/05/2022] [Indexed: 11/23/2022]
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Circular RNA FUNDC1 improves prediction of stroke associated infection in acute ischemic stroke patients with high risk. Biosci Rep 2021; 40:225258. [PMID: 32537657 PMCID: PMC7303347 DOI: 10.1042/bsr20200902] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/31/2020] [Accepted: 06/11/2020] [Indexed: 02/06/2023] Open
Abstract
Identifying those patients who were at high risk of stroke associated infection (SAI) for preventive antibiotic therapy was imperative for patients’ benefits, thus improving prediction of SAI was critical for all acute ischemic stroke (AIS) patients. Circular RNA FUNDC1 (circFUNDC1) has been reported to be the diagnosis and prognosis biomarker of AIS. Therefore, the present study aimed to figure out whether circFUNDC1 could be the potential predictor of SAI that could help to guide preventive treatment. In total, 68 patients were included in the study, 26 of which had infection and 42 without. Copy number of circFUNDC1 in plasma were quantified by quantitative real-time polymerase chain reaction (qPCR). Platelet spike-in experiment and correlation analysis were conducted to explore possible origins of circFUNDC1 in plasma. A significantly elevated level of circFUNDC1 was found in SAI patients compared with not infected AIS patients (P=0.0258). Receiver operating characteristic (ROC) curves demonstrated the prediction significance of circFUNDC1, with the area under the curve (AUC) at 0.6612 and sensitivity, specificity at 69.23%, 61.90% respectively in predicting SAI. Then, when adding circFUNDC1 in the risk model, the AUC increased from 0.7971 in model A to 0.8038 in model B. Additionally, positive correlation was observed between circFUNDC1 level and neutrophils counts. WBC and neutrophil ratios were significantly elevated in SAI patients compared with non-SAI patients. Therefore, circFUNDC1 could be used to construct a risk model for the prediction of SAI that is beneficial for AIS patients’ preventive treatment.
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de Jonge JC, Woodhouse LJ, Reinink H, van der Worp HB, Bath PM. PRECIOUS: PREvention of Complications to Improve OUtcome in elderly patients with acute Stroke-statistical analysis plan of a randomised, open, phase III, clinical trial with blinded outcome assessment. Trials 2020; 21:884. [PMID: 33106180 PMCID: PMC7586648 DOI: 10.1186/s13063-020-04717-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/31/2020] [Indexed: 12/01/2022] Open
Abstract
Rationale Aspiration, infections, and fever are common in the first days after stroke, especially in older patients. The occurrence of these complications has been associated with an increased risk of death or dependency. Aims and design PREvention of Complications to Improve OUtcome in elderly patients with acute Stroke (PRECIOUS) is an international, multi-centre, 3 × 2 factorial, randomised, controlled, open-label clinical trial with blinded outcome assessment, which will assess whether prevention of aspiration, infections, or fever with metoclopramide, ceftriaxone, paracetamol, respectively, or any combination of these in the first 4 days after stroke onset improves functional outcome at 90 days in elderly patients with acute stroke. Discussion This statistical analysis plan provides a technical description of the statistical methodology and unpopulated tables and figures. The paper is written prior to data lock and unblinding of treatment allocation. Trial registration ISRCTN registry ISRCTN82217627. Registered on 22 September 2015. The trial was prospectively registered.
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Affiliation(s)
- Jeroen C de Jonge
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Lisa J Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Hendrik Reinink
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Boehme AK, Kulick ER, Canning M, Alvord T, Khaksari B, Omran S, Willey JZ, Elkind MSV. Infections Increase the Risk of 30-Day Readmissions Among Stroke Survivors. Stroke 2019; 49:2999-3005. [PMID: 30571394 DOI: 10.1161/strokeaha.118.022837] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Hospitals are increasingly using 30-day readmission (30dRA) to define the quality of care and reimbursement. We hypothesized that common infections occurring during the stroke stay are associated with 30dRA. Methods- We conducted a weighted analysis of the federally managed 2013 National Readmission Database to assess the relationship between infection during a stroke hospitalization and 30dRA among ischemic stroke survivors. Ischemic stroke, common infections (defined as sepsis, pneumonia, and urinary tract infection), and comorbidities were identified using International Classification of Diseases Ninth Revision ( ICD-9) diagnosis codes, and intravenous tPA (tissue-type plasminogen activator) or intra-arterial therapy was identified using ICD-9 procedure codes. Survey design logistic regression models were fit to estimate crude and adjusted odds ratios and 95% CI for the association between infections and 30dRA. Results- Among 319 317 ischemic stroke patients, 12.1% were readmitted within 30 days, and 29% had an infection during their index hospitalization. Patients with infection during their stroke admission had a 21% higher odds of being readmitted than patients without any type of infection (adjusted odds ratio, 1.21; 95% CI, 1.16-1.26). The association between infection and unplanned readmission was similar with an increased odds of unplanned readmission (adjusted odds ratio, 1.23; 95% CI, 1.18-1.29). When assessing specific types of infections, only urinary tract infections were associated with 30dRA in adjusted models (odds ratio, 1.10; 95% CI, 1.04-1.16). Conclusions- In a nationally representative cohort, patients who had a common infection during their stroke hospitalization were at increased odds of being readmitted. Patients with infection may benefit from earlier poststroke follow-up or closer monitoring.
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Affiliation(s)
- Amelia K Boehme
- From the Department of Neurology, Vagelos College of Physicians and Surgeons (A.K.B., E.R.K., M.C., T.A., B.K., S.O., J.Z.W., M.S.V.E.), Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health (A.K.B., E.R.K., M.C., T.A., B.K., M.S.V.E.), Columbia University, New York, NY
| | - Erin R Kulick
- From the Department of Neurology, Vagelos College of Physicians and Surgeons (A.K.B., E.R.K., M.C., T.A., B.K., S.O., J.Z.W., M.S.V.E.), Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health (A.K.B., E.R.K., M.C., T.A., B.K., M.S.V.E.), Columbia University, New York, NY
| | - Michelle Canning
- From the Department of Neurology, Vagelos College of Physicians and Surgeons (A.K.B., E.R.K., M.C., T.A., B.K., S.O., J.Z.W., M.S.V.E.), Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health (A.K.B., E.R.K., M.C., T.A., B.K., M.S.V.E.), Columbia University, New York, NY
| | - Trevor Alvord
- From the Department of Neurology, Vagelos College of Physicians and Surgeons (A.K.B., E.R.K., M.C., T.A., B.K., S.O., J.Z.W., M.S.V.E.), Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health (A.K.B., E.R.K., M.C., T.A., B.K., M.S.V.E.), Columbia University, New York, NY
| | - Bijan Khaksari
- From the Department of Neurology, Vagelos College of Physicians and Surgeons (A.K.B., E.R.K., M.C., T.A., B.K., S.O., J.Z.W., M.S.V.E.), Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health (A.K.B., E.R.K., M.C., T.A., B.K., M.S.V.E.), Columbia University, New York, NY
| | - Setareh Omran
- From the Department of Neurology, Vagelos College of Physicians and Surgeons (A.K.B., E.R.K., M.C., T.A., B.K., S.O., J.Z.W., M.S.V.E.), Columbia University, New York, NY
| | - Joshua Z Willey
- From the Department of Neurology, Vagelos College of Physicians and Surgeons (A.K.B., E.R.K., M.C., T.A., B.K., S.O., J.Z.W., M.S.V.E.), Columbia University, New York, NY
| | - Mitchell S V Elkind
- From the Department of Neurology, Vagelos College of Physicians and Surgeons (A.K.B., E.R.K., M.C., T.A., B.K., S.O., J.Z.W., M.S.V.E.), Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health (A.K.B., E.R.K., M.C., T.A., B.K., M.S.V.E.), Columbia University, New York, NY
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Visvanathan A, Mead G, Dennis M, Whiteley W, Doubal F, Lawton J. Maintaining hope after a disabling stroke: A longitudinal qualitative study of patients' experiences, views, information needs and approaches towards making treatment decisions. PLoS One 2019; 14:e0222500. [PMID: 31518369 PMCID: PMC6743774 DOI: 10.1371/journal.pone.0222500] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 09/01/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Some treatments after a disabling stroke increase the likelihood patients will survive longer but with significant disability. Patients and doctors should make collaborative decisions regarding these treatments. However, this can be challenging. To better understand treatment decision-making in acute disabling stroke, we explored the experiences, views and needs of stroke survivors in hospital and six months later. METHODS Fifteen patients who had a disabling stroke were interviewed within a week of their diagnosis; eleven were re-interviewed six months later. Data were analysed thematically and longitudinally. RESULTS Patients' functional abilities prior to their stroke and need for hope of functional recovery appeared to impact on their involvement in decision-making. In the early period post stroke, patients who were functionally independent pre- stroke described being emotionally devastated and ill-prepared for the consequences of stroke. They appeared unaware that treatments offered might extend their life but with significant disability and took all treatments in the hope of functional recovery. Those who were dependent pre-stroke appeared to be more stoic, had considered treatment implications and decided against such treatments. At follow-up, all patients had varying unmet psychological needs which appeared to contribute to poor quality of life. In the early period post stroke, patients looked for various ways to cultivate and maintain hope of functional recovery. While patients continued to look for hope at six months, they also reported wishing they had been given realistic information in the early period after stroke in order to prepare for the consequences. CONCLUSION Stroke survivors may benefit from psychological support. A collaborative approach towards treatment decision-making may not be realistic in all patients especially when they may be emotionally distressed and looking to maintain a positive outlook. Communication strategies to balance maintaining hope without providing false hope may be appropriate. Patients' information needs may need reassessed at different time points.
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Affiliation(s)
- Akila Visvanathan
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, United Kingdom
| | - Gillian Mead
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, United Kingdom
| | - Martin Dennis
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, United Kingdom
| | - William Whiteley
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, United Kingdom
| | - Fergus Doubal
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, United Kingdom
| | - Julia Lawton
- Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, United Kingdom
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Reinink H, de Jonge JC, Bath PM, van de Beek D, Berge E, Borregaard S, Ciccone A, Csiba L, Demotes J, Dippel DW, Kõrv J, Kurkowska-Jastrzebska I, Lees KR, Macleod MR, Ntaios G, Randall G, Thomalla G, van der Worp HB. PRECIOUS: PREvention of Complications to Improve OUtcome in elderly patients with acute Stroke. Rationale and design of a randomised, open, phase III, clinical trial with blinded outcome assessment. Eur Stroke J 2018; 3:291-298. [PMID: 30246150 PMCID: PMC6120123 DOI: 10.1177/2396987318772687] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 03/28/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Elderly patients are at high risk of complications after stroke, such as infections and fever. The occurrence of these complications has been associated with an increased risk of death or dependency.Hypothesis: Prevention of aspiration, infections, or fever with metoclopramide, ceftriaxone, paracetamol, or any combination of these in the first four days after stroke onset will improve functional outcome at 90 days in elderly patients with acute stroke. DESIGN International, 3 × 2-factorial, randomised-controlled, open-label clinical trial with blinded outcome assessment (PROBE) in 3800 patients aged 66 years or older with acute ischaemic stroke or intracerebral haemorrhage and an NIHSS score ≥ 6. Patients will be randomly allocated to any combination of oral, rectal, or intravenous metoclopramide (10 mg thrice daily); intravenous ceftriaxone (2000 mg once daily); oral, rectal, or intravenous paracetamol (1000 mg four times daily); or usual care, started within 24 h after symptom onset and continued for four days or until complete recovery or discharge from hospital, if earlier.Outcome: The primary outcome measure is the score on the modified Rankin Scale at 90 days (± 14 days), as analysed with multiple regression.Summary: This trial will provide evidence for a simple, safe and generally available treatment strategy that may reduce the burden of death or disability in patients with stroke at very low costs.Planning: First patient included in May 2016; final follow-up of the last patient by April 2020.Registration: ISRCTN, ISRCTN82217627, https://doi.org/10.1186/ISRCTN82217627.
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Affiliation(s)
- Hendrik Reinink
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus Institute, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jeroen C de Jonge
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus Institute, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Diederik van de Beek
- Department of Neurology, Academic Medical Center, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Eivind Berge
- Department of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Alfonso Ciccone
- Department of Neurology and Stroke Unit, ASST di Mantova, Mantua, Italy
| | - Laszlo Csiba
- Department of Neurology, University of Debrecen, Debrecen, Hungary
| | - Jacques Demotes
- European Clinical Research Infrastructure Network (ECRIN), Paris, France
| | - Diederik W Dippel
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia
| | | | - Kennedy R Lees
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Malcolm R Macleod
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - George Ntaios
- Department of Medicine, Larissa University Hospital, University of Thessaly, Larissa, Greece
| | - Gary Randall
- Stroke Alliance for Europe (SAFE), Brussels, Belgium
| | - Götz Thomalla
- Department of Neurology, Center for Clinical Neurosciences, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus Institute, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Shi K, Wood K, Shi FD, Wang X, Liu Q. Stroke-induced immunosuppression and poststroke infection. Stroke Vasc Neurol 2018; 3:34-41. [PMID: 29600006 PMCID: PMC5870641 DOI: 10.1136/svn-2017-000123] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 12/03/2017] [Accepted: 12/11/2017] [Indexed: 02/04/2023] Open
Abstract
Infections occur commonly after stroke and are strongly associated with an unfavourable functional outcome of these patients. Approaches for effective management of poststroke infection remain scarce, presenting an urgent need for preventive anti-infection strategies for patients who have suffered a stroke. Emerging evidence indicates that stroke impairs systemic immune responses and increases the susceptibility to infections, suggesting that the modification of impaired immune defence could be beneficial. In this review, we summarised previous attempts to prevent poststroke infections using prophylactic antibiotics and the current understanding of stroke-induced immunosuppression. Further elucidation of the immune mechanisms of stroke will pave the way to tailored design of new treatment to combat poststroke infection via modifying the immune system.
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Affiliation(s)
- Kaibin Shi
- Departments of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
- Departments of Neurology, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kristofer Wood
- Departments of Neurology, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, USA
| | - Fu-Dong Shi
- Departments of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
- Departments of Neurology, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, USA
| | - Xiaoying Wang
- Departments of Neurology and Radiology, Neuroprotection Research Laboratory, Massachusetts General Hospital, Neuroscience Program, Harvard Medical School, Boston, Massachusetts, USA
| | - Qiang Liu
- Departments of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
- Departments of Neurology, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, USA
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Vermeij J, Westendorp WF, Dippel DWJ, van de Beek D, Nederkoorn PJ. Antibiotic therapy for preventing infections in people with acute stroke. Cochrane Database Syst Rev 2018; 1:CD008530. [PMID: 29355906 PMCID: PMC6491314 DOI: 10.1002/14651858.cd008530.pub3] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Stroke is the main cause of disability in high-income countries and ranks second as a cause of death worldwide. Infections occur frequently after stroke and may adversely affect outcome. Preventive antibiotic therapy in the acute phase of stroke may reduce the incidence of infections and improve outcome. In the previous version of this Cochrane Review, published in 2012, we found that antibiotics did reduce the risk of infection but did not reduce the number of dependent or deceased patients. However, included studies were small and heterogeneous. In 2015, two large clinical trials were published, warranting an update of this Review. OBJECTIVES To assess the effectiveness and safety of preventive antibiotic therapy in people with ischaemic or haemorrhagic stroke. We wished to determine whether preventive antibiotic therapy in people with acute stroke:• reduces the risk of a poor functional outcome (dependency and/or death) at follow-up;• reduces the occurrence of infections in the acute phase of stroke;• reduces the occurrence of elevated body temperature (temperature ≥ 38° C) in the acute phase of stroke;• reduces length of hospital stay; or• leads to an increased rate of serious adverse events, such as anaphylactic shock, skin rash, or colonisation with antibiotic-resistant micro-organisms. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (25 June 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 5; 25 June 2017) in the Cochrane Library; MEDLINE Ovid (1950 to 11 May 2017), and Embase Ovid (1980 to 11 May 2017). In an effort to identify further published, unpublished, and ongoing trials, we searched trials and research registers, scanned reference lists, and contacted trial authors, colleagues, and researchers in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) of preventive antibiotic therapy versus control (placebo or open control) in people with acute ischaemic or haemorrhagic stroke. DATA COLLECTION AND ANALYSIS Two review authors independently selected articles and extracted data; we discussed and resolved discrepancies at a consensus meeting with a third review author. We contacted study authors to obtain missing data when required. An independent review author assessed risk of bias using the Cochrane 'Risk of bias' tool. We calculated risk ratios (RRs) for dichotomous outcomes, assessed heterogeneity amongst included studies, and performed subgroup analyses on study quality. MAIN RESULTS We included eight studies involving 4488 participants. Regarding quality of evidence, trials showed differences in study population, study design, type of antibiotic, and definition of infection; however, primary outcomes among the included studies were consistent. Mortality rate in the preventive antibiotic group was not significantly different from that in the control group (373/2208 (17%) vs 360/2214 (16%); RR 1.03, 95% confidence interval (CI) 0.87 to 1.21; high-quality evidence). The number of participants with a poor functional outcome (death or dependency) in the preventive antibiotic therapy group was also not significantly different from that in the control group (1158/2168 (53%) vs 1182/2164 (55%); RR 0.99, 95% CI 0.89 to 1.10; moderate-quality evidence). However, preventive antibiotic therapy did significantly reduce the incidence of 'overall' infections in participants with acute stroke from 26% to 19% (408/2161 (19%) vs 558/2156 (26%); RR 0.71, 95% CI 0.58 to 0.88; high-quality evidence). This finding was highly significant for urinary tract infections (81/2131 (4%) vs 204/2126 (10%); RR 0.40, 95% CI 0.32 to 0.51; high-quality evidence), whereas no preventive effect for pneumonia was found (222/2131 (10%) vs 235/2126 (11%); RR 0.95, 95% CI 0.80 to 1.13; high-quality evidence). No major side effects of preventive antibiotic therapy were reported. Only two studies qualitatively assessed the occurrence of elevated body temperature; therefore, these results could not be pooled. Only one study reported length of hospital stay. AUTHORS' CONCLUSIONS Preventive antibiotics had no effect on functional outcome or mortality, but significantly reduced the risk of 'overall' infections. This reduction was driven mainly by prevention of urinary tract infection; no effect for pneumonia was found.
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Affiliation(s)
- Jan‐Dirk Vermeij
- University of AmsterdamDepartment of Neurology, Academic Medical CentrePO Box 22660AmsterdamNetherlands1100 DD
| | - Willeke F Westendorp
- University of AmsterdamDepartment of Neurology, Academic Medical CentrePO Box 22660AmsterdamNetherlands1100 DD
| | - Diederik WJ Dippel
- Erasmus MC University Medical CenterPO Box 2040RotterdamNetherlands3000 CA
| | - Diederik van de Beek
- University of AmsterdamDepartment of Neurology, Academic Medical CentrePO Box 22660AmsterdamNetherlands1100 DD
| | - Paul J Nederkoorn
- University of AmsterdamDepartment of Neurology, Academic Medical CentrePO Box 22660AmsterdamNetherlands1100 DD
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Zheng F, von Spreckelsen N, Zhang X, Stavrinou P, Timmer M, Dohmen C, Goldbrunner R, Cao F, Zhang Q, Ran Q, Li G, Fan R, Yao S, Krischek B. Should preventive antibiotics be used in patients with acute stroke? A systematic review and meta-analysis of randomized controlled trials. PLoS One 2017; 12:e0186607. [PMID: 29049353 PMCID: PMC5648227 DOI: 10.1371/journal.pone.0186607] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 10/04/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Infection is a common complication in acute stroke. Whether or not preventive antibiotics reduce the risk of infection or even lead to a favorable outcome and reduction of mortality after a stroke still remains equivocal. This review was performed to update the current knowledge on the effect and possible benefits of prophylactic antibiotic therapy in patients with stroke. METHODS A systematic review and meta-analysis of preventive antibiotics`effect on the incidence of infection, favorable outcome (mRS≤2) and mortality in patients with acute stroke is performed with relevant randomized controlled trials. RESULTS Six studies were identified, involving 4125 participants. Compared with the control group, the treated groups were significantly less prone to suffer from early overall infections [RR = 0.52, 95%CI (0.39, 0.70), p<0.0001], early pneumonia [RR = 0.64, 95%CI (0.42, 0.96), p = 0.03] and early urinary tract infections [RR = 0.35, 95%CI (0.25, 0.48), p<0.00001]. However, there was no significant difference in overall mortality [RR = 1.07, 95%CI (0.90, 1.27), p = 0.44], early mortality [RR = 0.99, 95%CI (0.78, 1.26), p = 0.92], late mortality [RR = 1.12, 95%CI (0.94, 1.35), p = 0.21] or favorable outcome [RR = 1.00, 95%CI (0.92, 1.08), p = 0.98]. CONCLUSION Although preventive antibiotic treatment did reduce the occurrence of early overall infections, early pneumonia and early urinary tract infection in patients with acute stroke, this advantage was not eventually translated to a favorable outcome and reduction in mortality. Future studies are warranted to identify any subgroup of stroke patients who might benefit from preventive antibiotic treatment.
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Affiliation(s)
- Feng Zheng
- Department of Neurosurgery, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
- * E-mail: (BK); (FZ)
| | | | - Xintong Zhang
- Department of Neurosurgery, The Second Clinical Medical School of Inner Mongolia University for the Nationalities (Inner Mongolia Forestry General Hospital), Inner Mongolia, China
| | - Pantelis Stavrinou
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Marco Timmer
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Christian Dohmen
- Department of Neurology, University Hospital of Cologne, Cologne, Germany
| | - Roland Goldbrunner
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Fang Cao
- Department of Cerebrovascular Disease, the first affiliated hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Qiang Zhang
- Department of Cerebrovascular Disease, the first affiliated hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Qishan Ran
- Department of Cerebrovascular Disease, the first affiliated hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Gang Li
- Department of Cerebrovascular Disease, the first affiliated hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Ruiming Fan
- Department of Cerebrovascular Disease, the first affiliated hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Shengtao Yao
- Department of Cerebrovascular Disease, the first affiliated hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Boris Krischek
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
- * E-mail: (BK); (FZ)
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Xi YG, Tian X, Chen WQ, Zhang S, Zhang S, Ren WD, Pang QJ, Yang GT, Yang ZM. Antibiotic prophylaxis for infections in patients with acute stroke: a systematic review and meta-analysis of randomized controlled trials. Oncotarget 2017; 8:81075-81087. [PMID: 29113368 PMCID: PMC5655263 DOI: 10.18632/oncotarget.19039] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 06/17/2017] [Indexed: 12/18/2022] Open
Abstract
Objective Infections are frequent after stroke and lead to increased mortality and neurological disability. Antibiotic prophylaxis has potential of decreasing the risk of infections and mortality and improving poor functional outcome. Several studies evaluated antibiotic prophylaxis for infections in acute stroke patients have generated conflicting results. The systematic review of randomized clinical trials (RCTs) aimed at comprehensively assessing the evidence of antibiotic prophylaxis for the treatment of acute stroke patients. Materials and Methods PubMed, EMBASE, the Cochrane library and the reference lists of eligible articles were searched to identify all potential studies. We included the studies that investigated the efficacy and safety of antibiotic prophylaxis for the treatment of acute stroke patients. The primary outcome included mortality and infection rate. The secondary outcomes included poor functional outcome and adverse events. Results Seven trials randomizing 4,261 patients were included. Pooled analyses showed that antibiotic prophylaxis did not improve the mortality (risk ratio (RR) = 1.03, 95% confidence interval (CI) 0.84 to 1.26, p = 0.78, I2 = 25%) and poor functional outcome (RR = 0.93, 95% CI 0.80 to 1.08, p = 0.32, I2 = 80%), but reduced the incidence of infection (RR = 0.67, 95% CI 0.53 to 0.84, p = 0.0007, I2 = 49%). No major side effects were reported. Sensitivity analyses confirmed the results of infection rate and poor functional outcome. Conclusions Antibiotic prophylaxis can be used to treat the infectious events of acute stroke patients although it has no potential of decreased mortality and improved functional outcome.
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Affiliation(s)
- Yan-Guo Xi
- Department of Neurosurgery, Cang Zhou Central Hospital, Hebei 061001, China
| | - Xu Tian
- Department of Gastroenterology, Chongqing Cancer Institute and Hospital and Cancer Center, Chongqing 400030, China
| | - Wei-Qing Chen
- Department of Gastroenterology, Chongqing Cancer Institute and Hospital and Cancer Center, Chongqing 400030, China
| | - Sai Zhang
- Department of Neurosurgery, Logistic University Affiliated Hospital, Logistic University of Chinese People's Armed Police Force, Tianjin 300162, China
| | - Shan Zhang
- Department of Neurosurgery, Cang Zhou Central Hospital, Hebei 061001, China
| | - Wei-Dan Ren
- Department of Neurosurgery, Cang Zhou Central Hospital, Hebei 061001, China
| | - Qi-Jun Pang
- Department of Neurosurgery, Cang Zhou Central Hospital, Hebei 061001, China
| | - Guo-Tao Yang
- Department of Neurosurgery, Cang Zhou Central Hospital, Hebei 061001, China
| | - Zhi-Ming Yang
- Department of Neurosurgery, Cang Zhou Central Hospital, Hebei 061001, China
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11
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Righy C, do Brasil PEA, Vallés J, Bozza FA, Martin-Loeches I. Systemic antibiotics for preventing ventilator-associated pneumonia in comatose patients: a systematic review and meta-analysis. Ann Intensive Care 2017. [PMID: 28620893 PMCID: PMC5472643 DOI: 10.1186/s13613-017-0291-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Early-onset ventilator-associated pneumonia (EO-VAP) is the leading cause of morbidity and mortality in comatose patients. However, VAP prevention bundles focus mainly on late-onset VAP and may be less effective in preventing EO-VAP in comatose patients. Systemic antibiotic administration at the time of intubation may have a role in preventing EO-VAP. Therefore, we evaluated the effectiveness of systemic antibiotic administration in VAP prevention in comatose patients through a systematic review and meta-analysis. METHODS We searched for studies published through December 2015 that evaluated systemic antibiotic prophylaxis in comatose patients. Two authors independently selected and evaluated full-length reports of randomized clinical trials or prospective cohorts in patients aged >16 years that evaluated the impact of systemic antibiotics at the time of intubation on EO-VAP compared to placebo or no prophylaxis. The outcome variables were the incidence of EO-VAP, the duration of mechanical ventilation, ICU length of stay, and ICU mortality. RESULTS We identified 10,988 citations, yielding 26 articles for further analysis; three studies with 267 patients were finally analyzed. Most patients (n = 135) were comatose due to head trauma. Systemic antibiotic administration was associated with decreased incidence of EO-VAP (RR 0.32; 95% CI 0.19-0.54) and shorter ICU LOS (standardized mean difference -0.32; 95% CI -0.56 to -0.08), but had no effect on mortality (RR 1.03; 95% CI 0.7-1.53) or duration of mechanical ventilation (standardized mean difference -0.16; 95% CI -0.41 to 0.08). CONCLUSIONS Antibiotic prophylaxis in comatose patients reduced the incidence of EO-VAP and decreased the ICU stay slightly. Future trials are needed to confirm these results.
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Affiliation(s)
- Cássia Righy
- National Institute of Infectious Disease Evandro Chagas, Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Brazil. .,ICU, Paulo Niemeyer Brain Institute, Rio de Janeiro, Brazil.
| | | | - Jordi Vallés
- CIBER Enfermedades Respiratorias (CIBERES), Barcelona, Spain.,Critical Care Center, CIBER Enfermedades Respiratorias, Hospital Sabadell, Sabadell, Spain
| | - Fernando A Bozza
- National Institute of Infectious Disease Evandro Chagas, Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Brazil.,IDOR, D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Ignacio Martin-Loeches
- CIBER Enfermedades Respiratorias (CIBERES), Barcelona, Spain.,Department of Clinical Medicine, Trinity Centre for Health Sciences, Multidisciplinary Intensive Care Research Organization (MICRO), Wellcome Trust, HRB Clinical Research, St James's University Hospital Dublin, Dublin, Ireland.,Irish Centre for Vascular Biology (ICVB), Dublin, Ireland
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12
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Donkor ES, Darkwah S, Akpalu A. Post-Stroke Bacteriuria: A Longitudinal Study among Stroke Outpatients and Inpatients at the Korle-Bu Teaching Hospital in Ghana. Med Sci (Basel) 2017; 5:medsci5020011. [PMID: 29099028 PMCID: PMC5635783 DOI: 10.3390/medsci5020011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 05/17/2017] [Accepted: 05/19/2017] [Indexed: 12/13/2022] Open
Abstract
Infections of the urinary tract constitute an important post-stroke complication but in Africa, little is known about such infections in relation to stroke patients. The aim of the study was to investigate the epidemiology of bacteriuria among stroke patients at the Korle-Bu Teaching Hospital (KBTH) in Ghana including the prevalence, incidence, risk factors and aetiological agents. This was a longitudinal study involving 55 outpatients and 16 inpatients of stroke from the physiotherapy clinic and stroke admission ward of KBTH respectively. Urine cultures for inpatient subjects were done each day until the patient was discharged. With outpatients, urine specimens were analysed every week or two for 6 months. Information on demographics and clinical history of the study participants were extracted from their clinical records. The results showed that the prevalence of bacteriuria among stroke outpatients and inpatients were 10.9% (6/55) and 18.8% (3/16) respectively (p = 0.411). Among both the outpatients and inpatients, there was one new case of bacteriuria each during the period of follow-up. Overall, 1/9 (11%) of the bacteriuria cases among the stroke patients was symptomatic. Severe stroke (OR = 17.7, p = 0.008) and pyuria (OR = 38.7, p = 0.002) were identified as predictors of bacteriuria. Escherichia coli was the most common organism implicated in bacteriuria and was susceptible to amikacin, but resistant to augmentin, ampicillin, cefuroxime, cotrimoxazole, meropenem, norfloxacin and tetracycline. Overall, bacteriuria is a common complication among both stroke inpatients and outpatients at KBTH, though it appears to be more common among the former. Stroke severity appears to be the main stroke-related determinant of bacteriuria among stroke patients. Bacteriuria among stroke patients is mainly asymptomatic and E. coli is the most important aetiological agent.
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Affiliation(s)
- Eric S Donkor
- Department of Medical Microbiology, School of Biomedical and Allied Health Sciences University of Ghana, Accra, Ghana.
| | - Samuel Darkwah
- Department of Medical Microbiology, School of Biomedical and Allied Health Sciences University of Ghana, Accra, Ghana.
| | - Albert Akpalu
- Department of Medicine, School of Medicine and Dentistry, University of Ghana, Accra, Ghana.
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13
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Dreier JP, Fabricius M, Ayata C, Sakowitz OW, William Shuttleworth C, Dohmen C, Graf R, Vajkoczy P, Helbok R, Suzuki M, Schiefecker AJ, Major S, Winkler MKL, Kang EJ, Milakara D, Oliveira-Ferreira AI, Reiffurth C, Revankar GS, Sugimoto K, Dengler NF, Hecht N, Foreman B, Feyen B, Kondziella D, Friberg CK, Piilgaard H, Rosenthal ES, Westover MB, Maslarova A, Santos E, Hertle D, Sánchez-Porras R, Jewell SL, Balança B, Platz J, Hinzman JM, Lückl J, Schoknecht K, Schöll M, Drenckhahn C, Feuerstein D, Eriksen N, Horst V, Bretz JS, Jahnke P, Scheel M, Bohner G, Rostrup E, Pakkenberg B, Heinemann U, Claassen J, Carlson AP, Kowoll CM, Lublinsky S, Chassidim Y, Shelef I, Friedman A, Brinker G, Reiner M, Kirov SA, Andrew RD, Farkas E, Güresir E, Vatter H, Chung LS, Brennan KC, Lieutaud T, Marinesco S, Maas AIR, Sahuquillo J, Dahlem MA, Richter F, Herreras O, Boutelle MG, Okonkwo DO, Bullock MR, Witte OW, Martus P, van den Maagdenberg AMJM, Ferrari MD, Dijkhuizen RM, Shutter LA, Andaluz N, Schulte AP, MacVicar B, Watanabe T, Woitzik J, Lauritzen M, Strong AJ, Hartings JA. Recording, analysis, and interpretation of spreading depolarizations in neurointensive care: Review and recommendations of the COSBID research group. J Cereb Blood Flow Metab 2017; 37:1595-1625. [PMID: 27317657 PMCID: PMC5435289 DOI: 10.1177/0271678x16654496] [Citation(s) in RCA: 241] [Impact Index Per Article: 34.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 05/04/2016] [Accepted: 05/06/2016] [Indexed: 01/18/2023]
Abstract
Spreading depolarizations (SD) are waves of abrupt, near-complete breakdown of neuronal transmembrane ion gradients, are the largest possible pathophysiologic disruption of viable cerebral gray matter, and are a crucial mechanism of lesion development. Spreading depolarizations are increasingly recorded during multimodal neuromonitoring in neurocritical care as a causal biomarker providing a diagnostic summary measure of metabolic failure and excitotoxic injury. Focal ischemia causes spreading depolarization within minutes. Further spreading depolarizations arise for hours to days due to energy supply-demand mismatch in viable tissue. Spreading depolarizations exacerbate neuronal injury through prolonged ionic breakdown and spreading depolarization-related hypoperfusion (spreading ischemia). Local duration of the depolarization indicates local tissue energy status and risk of injury. Regional electrocorticographic monitoring affords even remote detection of injury because spreading depolarizations propagate widely from ischemic or metabolically stressed zones; characteristic patterns, including temporal clusters of spreading depolarizations and persistent depression of spontaneous cortical activity, can be recognized and quantified. Here, we describe the experimental basis for interpreting these patterns and illustrate their translation to human disease. We further provide consensus recommendations for electrocorticographic methods to record, classify, and score spreading depolarizations and associated spreading depressions. These methods offer distinct advantages over other neuromonitoring modalities and allow for future refinement through less invasive and more automated approaches.
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Affiliation(s)
- Jens P Dreier
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Martin Fabricius
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark
| | - Cenk Ayata
- Neurovascular Research Laboratory, Department of Radiology, and Stroke Service and Neuroscience Intensive Care Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Oliver W Sakowitz
- Department of Neurosurgery, Klinikum Ludwigsburg, Ludwigsburg, Germany
- Department of Neurosurgery, University Hospital, Heidelberg, Germany
| | - C William Shuttleworth
- Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Christian Dohmen
- Department of Neurology, University of Cologne, Cologne, Germany
- Multimodal Imaging of Brain Metabolism, Max-Planck-Institute for Metabolism Research, Cologne, Germany
| | - Rudolf Graf
- Multimodal Imaging of Brain Metabolism, Max-Planck-Institute for Metabolism Research, Cologne, Germany
| | - Peter Vajkoczy
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany
| | - Raimund Helbok
- Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Innsbruck, Austria
| | - Michiyasu Suzuki
- Department of Neurosurgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Alois J Schiefecker
- Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Innsbruck, Austria
| | - Sebastian Major
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Maren KL Winkler
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
| | - Eun-Jeung Kang
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Denny Milakara
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
| | - Ana I Oliveira-Ferreira
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Clemens Reiffurth
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Gajanan S Revankar
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
| | - Kazutaka Sugimoto
- Department of Neurosurgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Nora F Dengler
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany
| | - Nils Hecht
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, Neurocritical Care Division, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Bart Feyen
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | | | | | - Henning Piilgaard
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anna Maslarova
- Department of Neurosurgery, University Hospital and University of Bonn, Bonn, Germany
| | - Edgar Santos
- Department of Neurosurgery, University Hospital, Heidelberg, Germany
| | - Daniel Hertle
- Department of Neurosurgery, University Hospital, Heidelberg, Germany
| | | | - Sharon L Jewell
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Baptiste Balança
- Inserm U10128, CNRS UMR5292, Lyon Neuroscience Research Center, Team TIGER, Lyon, France
- Université Claude Bernard, Lyon, France
| | - Johannes Platz
- Department of Neurosurgery, Goethe-University, Frankfurt, Germany
| | - Jason M Hinzman
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Janos Lückl
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
| | - Karl Schoknecht
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité University Medicine Berlin, Berlin, Germany
- Neuroscience Research Center, Charité University Medicine Berlin, Berlin, Germany
| | - Michael Schöll
- Department of Neurosurgery, University Hospital, Heidelberg, Germany
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Christoph Drenckhahn
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Neurological Center, Segeberger Kliniken, Bad Segeberg, Germany
| | - Delphine Feuerstein
- Multimodal Imaging of Brain Metabolism, Max-Planck-Institute for Metabolism Research, Cologne, Germany
| | - Nina Eriksen
- Department of Clinical Physiology and Nuclear Medicine, Rigshospitalet, Copenhagen, Denmark
- Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Viktor Horst
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neuroradiology, Charité University Medicine Berlin, Berlin, Germany
| | - Julia S Bretz
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neuroradiology, Charité University Medicine Berlin, Berlin, Germany
| | - Paul Jahnke
- Department of Neuroradiology, Charité University Medicine Berlin, Berlin, Germany
| | - Michael Scheel
- Department of Neuroradiology, Charité University Medicine Berlin, Berlin, Germany
| | - Georg Bohner
- Department of Neuroradiology, Charité University Medicine Berlin, Berlin, Germany
| | - Egill Rostrup
- Department of Clinical Physiology and Nuclear Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Bente Pakkenberg
- Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, Panum Institute, University of Copenhagen, Copenhagen, Denmark
| | - Uwe Heinemann
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Neuroscience Research Center, Charité University Medicine Berlin, Berlin, Germany
| | - Jan Claassen
- Neurocritical Care, Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - Andrew P Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Christina M Kowoll
- Department of Neurology, University of Cologne, Cologne, Germany
- Multimodal Imaging of Brain Metabolism, Max-Planck-Institute for Metabolism Research, Cologne, Germany
| | - Svetlana Lublinsky
- Department of Physiology and Cell Biology, Zlotowski Center for Neuroscience, Beer-Sheva, Israel
- Department of Neuroradiology, Soroka University Medical Center and Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yoash Chassidim
- Department of Physiology and Cell Biology, Zlotowski Center for Neuroscience, Beer-Sheva, Israel
- Department of Neuroradiology, Soroka University Medical Center and Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ilan Shelef
- Department of Neuroradiology, Soroka University Medical Center and Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Alon Friedman
- Department of Physiology and Cell Biology, Zlotowski Center for Neuroscience, Beer-Sheva, Israel
- Department of Medical Neuroscience, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Gerrit Brinker
- Department of Neurosurgery, University of Cologne, Cologne, Germany
| | - Michael Reiner
- Department of Neurosurgery, University of Cologne, Cologne, Germany
| | - Sergei A Kirov
- Department of Neurosurgery and Brain and Behavior Discovery Institute, Medical College of Georgia, Augusta, GA, USA
| | - R David Andrew
- Department of Biomedical & Molecular Sciences, Queen’s University, Kingston, Canada
| | - Eszter Farkas
- Department of Medical Physics and Informatics, Faculty of Medicine, and Faculty of Science and Informatics, University of Szeged, Szeged, Hungary
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital and University of Bonn, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital and University of Bonn, Bonn, Germany
| | - Lee S Chung
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - KC Brennan
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Thomas Lieutaud
- Inserm U10128, CNRS UMR5292, Lyon Neuroscience Research Center, Team TIGER, Lyon, France
- Université Claude Bernard, Lyon, France
| | - Stephane Marinesco
- Inserm U10128, CNRS UMR5292, Lyon Neuroscience Research Center, Team TIGER, Lyon, France
- AniRA-Neurochem Technological Platform, Lyon, France
| | - Andrew IR Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Juan Sahuquillo
- Department of Neurosurgery, Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Frank Richter
- Institute of Physiology I/Neurophysiology, Friedrich Schiller University Jena, Jena, Germany
| | - Oscar Herreras
- Department of Systems Neuroscience, Cajal Institute-CSIC, Madrid, Spain
| | | | - David O Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - M Ross Bullock
- Department of Neurological Surgery, University of Miami, Miami, FL, USA
| | - Otto W Witte
- Hans Berger Department of Neurology, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Peter Martus
- Institute for Clinical Epidemiology and Applied Biometry, University of Tübingen, Tübingen, Germany
| | - Arn MJM van den Maagdenberg
- Department of Human Genetics, Leiden University Medical Center, Leiden, the Netherlands
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Michel D Ferrari
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Rick M Dijkhuizen
- Center for Image Sciences, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Lori A Shutter
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Critical Care Medicine and Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Norberto Andaluz
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Mayfield Clinic, Cincinnati, OH, USA
| | - André P Schulte
- Department of Spinal Surgery, St. Franziskus Hospital Cologne, Cologne, Germany
| | - Brian MacVicar
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | | | - Johannes Woitzik
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany
| | - Martin Lauritzen
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark
- Department of Neuroscience and Pharmacology, Panum Institute, University of Copenhagen, Copenhagen, Denmark
| | - Anthony J Strong
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Jed A Hartings
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Mayfield Clinic, Cincinnati, OH, USA
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14
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Ulm L, Hoffmann S, Nabavi D, Hermans M, Mackert BM, Hamilton F, Schmehl I, Jungehuelsing GJ, Montaner J, Bustamante A, Katan M, Hartmann A, Ebmeyer S, Dinter C, Wiemer JC, Hertel S, Meisel C, Anker SD, Meisel A. The Randomized Controlled STRAWINSKI Trial: Procalcitonin-Guided Antibiotic Therapy after Stroke. Front Neurol 2017; 8:153. [PMID: 28484421 PMCID: PMC5402305 DOI: 10.3389/fneur.2017.00153] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 04/03/2017] [Indexed: 11/17/2022] Open
Abstract
Background Pneumonia is among the most common acute complications after stroke and is associated with poor long-term outcome. Biomarkers may help identifying stroke patients at high risk for developing stroke-associated pneumonia (SAP) and to guide early treatment. Aims This trial investigated whether procalcitonin (PCT) ultrasensitive (PCTus)-guided antibiotic treatment of SAP can improve functional outcome after stroke. Methods In this international, multicenter, randomized, controlled clinical trial with blinded assessment of outcomes, patients with severe ischemic stroke in the middle cerebral artery territory were randomly assigned within 40 h after symptom onset to PCTus-based antibiotic therapy guidance in addition to stroke unit care or standard stroke unit care alone. The primary endpoint was functional outcome at 3 months, defined according to the modified Rankin Scale (mRS) and dichotomized as acceptable (≤4) or unacceptable (≥5). Secondary endpoints included usage of antibiotics, infection rates, days of fever, and mortality. The trial was registered with http://ClinicalTrials.gov (Identifier NCT01264549). Results In the intention-to-treat-analysis based on 227 patients (112 in PCT and 115 in control group), 197 patients completed the 3-month follow-up. Adherence to PCT guidance was 65%. PCT-guided therapy did not improve functional outcome as measured by mRS (odds ratio 0.79; 95% confidence interval 0.45–1.35, p = 0.47). Pneumonia rate and mortality were similar in both groups. Days with fever tended to be lower (p = 0.055), whereas total number of days treated with antibiotics were higher (p = 0.004) in PCT compared to control group. A post hoc analysis including all PCT values in the intention-to-treat population demonstrated a significant increase on the first day of infection in patients with pneumonia and sepsis compared to patients with urinary tract infections or without infections (p < 0.0001). Conclusion PCTus-guided antibiotic therapy did not improve functional outcome at 3 months after severe ischemic stroke. PCT is a promising biomarker for early detection of pneumonia and sepsis in acute stroke patients.
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Affiliation(s)
- Lena Ulm
- NeuroCure Clinical Research Center, Charité - Universitaetsmedizin Berlin, Berlin, Germany.,Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.,Department of Neurology and Center for Stroke Research Berlin, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Sarah Hoffmann
- NeuroCure Clinical Research Center, Charité - Universitaetsmedizin Berlin, Berlin, Germany.,Department of Neurology and Center for Stroke Research Berlin, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Darius Nabavi
- Department of Neurology, Vivantes Klinikum Neukoelln, Berlin, Germany
| | - Marcella Hermans
- Department of Neurology, Vivantes Klinikum Neukoelln, Berlin, Germany
| | | | - Frank Hamilton
- Department of Neurology, Vivantes Auguste-Viktoria-Klinikum, Berlin, Germany
| | - Ingo Schmehl
- Department of Neurology, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Gerhard-Jan Jungehuelsing
- Department of Neurology and Center for Stroke Research Berlin, Charité - Universitaetsmedizin Berlin, Berlin, Germany.,Department of Neurology, Juedisches Krankenhaus Berlin, Berlin, Germany
| | - Joan Montaner
- Neurovascular Research Laboratory, Institut de Recerca, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alejandro Bustamante
- Neurovascular Research Laboratory, Institut de Recerca, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mira Katan
- Department of Neurology, Universitaetsspital Zuerich, Zurich, Switzerland
| | - Andreas Hartmann
- Department of Neurology, Klinikum Frankfurt Oder, Frankfurt Oder, Germany
| | - Stefan Ebmeyer
- Thermo Fisher Scientific BRAHMS GmbH, Hennigsdorf, Germany
| | | | - Jan C Wiemer
- Thermo Fisher Scientific BRAHMS GmbH, Hennigsdorf, Germany
| | - Sabine Hertel
- Thermo Fisher Scientific BRAHMS GmbH, Hennigsdorf, Germany
| | - Christian Meisel
- Department of Immunology, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Stefan D Anker
- Division of Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Centre Goettingen, Goettingen, Germany.,Centre for Clinical and Basic Research, IRCCS, Rome, Italy
| | - Andreas Meisel
- NeuroCure Clinical Research Center, Charité - Universitaetsmedizin Berlin, Berlin, Germany.,Department of Neurology and Center for Stroke Research Berlin, Charité - Universitaetsmedizin Berlin, Berlin, Germany
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15
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Preventive Antibiotics and Delayed Cerebral Ischaemia in Patients with Aneurysmal Subarachnoid Haemorrhage Admitted to the Intensive Care Unit. Neurocrit Care 2016; 24:122-7. [PMID: 26450848 DOI: 10.1007/s12028-015-0202-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Delayed cerebral ischemia (DCI) is an important contributor to poor outcome after aneurysmal subarachnoid haemorrhage (aSAH). Development of DCI is multifactorial, and inflammation, with or without infection, is one of the factors independently associated with development of DCI and poor outcome. We thus postulated that preventive antibiotics might be associated with a reduced risk of DCI and subsequent poor outcome in aSAH patients. METHODS We performed a retrospective cohort-study in intensive care units (ICU) of three university hospitals in The Netherlands. We included consecutive aSAH patients with minimal ICU stay of 72 h who received either preventive antibiotics (SDD: selective digestive tract decontamination including systemic cefotaxime or SOD: selective oropharyngeal decontamination) or no preventive antibiotics. DCI was defined as a new hypodensity on CT with no other explanation than DCI. Hazard ratio's (HR) for DCI and risk ratio's (RR) for 28-day case-fatality and poor outcome at 3 months were calculated, with adjustment (aHR/aRR) for clinical condition on admission, recurrent bleeding, aneurysm treatment modality and treatment site. RESULTS Of 459 included patients, 274 received preventive antibiotics (SOD or SDD) and 185 did not. With preventive antibiotics, the aHR for DCI was 1.0 (95% CI 0.6-1.8), the aRR for 28-day case-fatality was 1.1 (95% CI 0.7-1.9) and the aRR for poor functional outcome 1.2 (95% CI 1.0-1.4). CONCLUSIONS Preventive antibiotics were not associated with reduced risk of DCI or poor outcome in aSAH patients in the ICU.
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The Efficacy of Prophylactic Antibiotics on Post-Stroke Infections: An Updated Systematic Review and Meta-Analysis. Sci Rep 2016; 6:36656. [PMID: 27841284 PMCID: PMC5107889 DOI: 10.1038/srep36656] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 10/18/2016] [Indexed: 11/21/2022] Open
Abstract
Post-stroke infections are common complications in acute stroke patients and are associated with an unfavorable functional outcome. However, reports on the effects of prophylactic antibiotics treatment on post-stroke infections are conflicting, especially those on post-stroke pneumonia and outcomes. We searched the PubMed, Embase, and Web of Knowledge databases up through March 11th, 2016. Seven randomized controlled trials including 4261 patients were analyzed among this systematic review and meta-analysis. We found preventive antibiotics treatment at the time of stroke onset did reduce the incidence of infections in adults with acute stroke (OR = 0.57, 95% CI: 0.38–0.85, P = 0.005), including reducing the number of urinary tract infections (OR = 0.34, 95% CI: 0.26–0.46, P < 0.001), but did not significantly decrease the rate of post-stroke pneumonia (OR = 0.91, 95% CI: 0.73–1.13, P = 0.385). Importantly, antibiotics treatment also showed no significant effect on the number of fatalities among stroke patients (OR = 1.07, 95% CI: 0.90–1.26, P = 0.743) and functional outcome scores on the modified Rankin Scale (OR = 1.76, 95% CI: 0.86–3.63, p = 0.124). Our study indicated that preventive antibiotics treatment not reduced the rate of post-stroke pneumonia or mortality, even though decreased the risk of infections, especially urinary tract infections. Thus, preventive antibiotics treatment may not be recommended for acute stroke patients.
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Pássaro L, Harbarth S, Landelle C. Prevention of hospital-acquired pneumonia in non-ventilated adult patients: a narrative review. Antimicrob Resist Infect Control 2016; 5:43. [PMID: 27895901 PMCID: PMC5109660 DOI: 10.1186/s13756-016-0150-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 11/09/2016] [Indexed: 01/28/2023] Open
Abstract
Background Pneumonia is one of the leading hospital-acquired infections worldwide and has an important impact. Although preventive measures for ventilator-associated pneumonia (VAP) are well known, less is known about appropriate measures for prevention of hospital-acquired pneumonia (HAP). Aim The purpose of this narrative review is to provide an overview of the current standards for preventing HAP in non-ventilated adult patients. Methods A search of the literature up to May 2015 was conducted using Medline for guidelines published by national professional societies or professional medical associations. In addition, a comprehensive search for the following preventive measures was performed: hand hygiene, oral care, bed position, mobilization, diagnosis and treatment of dysphagia, aspiration prevention, viral infections and stress bleeding prophylaxis. Findings Regarding international guidelines, several measures were recommended for VAP, whilst no specific recommendations for HAP prevention in non-ventilated patients are available. There is reasonable evidence available that oral care is associated with a reduction in HAP. Early mobilization interventions, swift diagnosis and treatment of dysphagia, and multimodal programmes for the prevention of nosocomial influenza cross-infection, have a positive impact on HAP reduction. The impact of bed position and stress bleeding prophylaxis remains uncertain. Systematic antibiotic prophylaxis for HAP prevention should be avoided. Conclusion Scant literature and little guidance is available for the prevention of HAP among non-ventilated adult patients. In addition, the criteria used for the diagnosis of HAP and the populations targeted in the studies selected are heterogeneous. Oral care was the most studied measure and was commonly associated with a decrease in HAP rate, although a broad range of interventions are proposed. No robust evidence is available for other measures. Further high-quality studies are required to evaluate the impact of specific measures on HAP prevention in non-ventilated adult patients.
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Affiliation(s)
- Leonor Pássaro
- Infection Control Programme, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - Stephan Harbarth
- Infection Control Programme, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - Caroline Landelle
- Infection Control Programme, Geneva University Hospitals and Medical School, Geneva, Switzerland ; Infection Control Unit, Centre Hospitalier Universitaire (CHU) Grenoble Alpes, CS 10217, 38043 Grenoble Cedex 9, France ; ThEMAS TIM-C UMR 5525, University Grenoble Alpes/CNRS, Grenoble, France
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Intraventricular Bleeding and Hematoma Size as Predictors of Infection Development in Intracerebral Hemorrhage: A Prospective Cohort Study. J Stroke Cerebrovasc Dis 2016; 25:2708-2711. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.07.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 07/06/2016] [Accepted: 07/09/2016] [Indexed: 02/06/2023] Open
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Abstract
Infections, in particular pneumonia, are common complications in patients with acute stroke and are associated with a less favorable neurologic and functional outcome. Patients with severe stroke and dysphagia are at highest risk of infection. Experimental and clinical data suggest stroke-induced immunodeficiency as a major factor contributing to the high incidence of infection after stroke. Preclinical studies support the potential benefit of preventive antibiotic therapy in acute stroke for lowering the incidence of infection and improving clinical outcome. Several smaller clinical trials on preventive antibiotic therapy in patients with stroke conducted during the last 10 years yielded inconclusive results. Recently, 2 large, open-label, controlled trials failed to demonstrate an improved clinical outcome after preventive antibiotic therapy in patients with acute stroke treated in specialized stroke units. In the "Preventive Antibiotics in Stroke Study", antibiotic therapy lowered the rate of infection but did not influence outcome. In the STROKE-INF study, performed in patients with dysphagia after stroke, antibiotic therapy did not lower the incidence of pneumonia and had no prognostic significance. At present, preventive antibiotic therapy cannot be recommended as a therapeutic option for acute stroke.
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Affiliation(s)
- Stefan Schwarz
- Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany.
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20
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Matz K, Seyfang L, Dachenhausen A, Teuschl Y, Tuomilehto J, Brainin M. Post-stroke pneumonia at the stroke unit - a registry based analysis of contributing and protective factors. BMC Neurol 2016; 16:107. [PMID: 27430328 PMCID: PMC4949772 DOI: 10.1186/s12883-016-0627-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 06/17/2016] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND To investigate prevalence and risk factors for post stroke pneumonia (PSP) in patients with acute ischemic stroke treated at stroke units (SU). METHOD We analysed data from the Austrian Stroke Unit registry concerning admissions from January 2003 to December 2013 and assessed the prevalence of PSP at the stroke unit. Patients with and without PSP were compared in univariate and multivariate models searching for factors associated with the occurrence of PSP at the SU. RESULTS Three thousand one hundred eleven patients (5.2%) of 59,558 analysed patients were diagnosed with PSP. While age and stroke severity were non-modifiable factors associated with PSP, modifiable risk factors included chronic alcohol consumption and atrial fibrillation. Patients who developed neurological, cardiac, and other infective complications showed a higher prevalence of PSP, an increased prevalence was also found in connection with the placement of nasogastric tubes or urinary catheters. Female sex, left hemispheric stroke, cryptogenic stroke pathogenesis and additionally, treatment with lipid lowering drugs were factors associated with a lower PSP prevalence. CONCLUSION Pneumonia in acute ischemic stroke is associated with a variety of modifiable and unmodifiable factors that allow to identify patients at high risk of developing PSP and to focus on early preventive measures at the SU. Further studies could use the results of this study to explore potential benefits of specific interventions targeted at these factors.
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Affiliation(s)
- Karl Matz
- Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Dr.-Karl-Dorrek-Str. 30, A-3500, Krems, Austria. .,Department of Neurology, University Clinic Tulln, Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Krems, Austria.
| | - Leonhard Seyfang
- Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Dr.-Karl-Dorrek-Str. 30, A-3500, Krems, Austria
| | - Alexandra Dachenhausen
- Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Dr.-Karl-Dorrek-Str. 30, A-3500, Krems, Austria
| | - Yvonne Teuschl
- Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Dr.-Karl-Dorrek-Str. 30, A-3500, Krems, Austria
| | - Jaakko Tuomilehto
- Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Dr.-Karl-Dorrek-Str. 30, A-3500, Krems, Austria.,Department of Chronic Disease Prevention, National Institute for Health and Welfare, 00271, Helsinki, Finland.,Diabetes Research Group, King Abdulaziz University, 21589, Jeddah, Saudi Arabia
| | - Michael Brainin
- Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Dr.-Karl-Dorrek-Str. 30, A-3500, Krems, Austria.,Department of Neurology, University Clinic Tulln, Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Krems, Austria
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Vermeij JD, Westendorp WF, Roos YB, Brouwer MC, van de Beek D, Nederkoorn PJ. Preventive Ceftriaxone in Patients with Stroke Treated with Intravenous Thrombolysis: Post Hoc Analysis of the Preventive Antibiotics in Stroke Study. Cerebrovasc Dis 2016; 42:361-369. [PMID: 27336314 DOI: 10.1159/000446160] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 04/10/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The Preventive Antibiotics in Stroke Study (PASS), a randomized open-label masked endpoint trial, showed that preventive ceftriaxone did not improve functional outcome at 3 months in patients with acute stroke (adjusted common OR 0.95; 95% CI 0.82-1.09). Post-hoc analyses showed that among patients who received intravenous thrombolysis (IVT), patients who received ceftriaxone had a significantly better outcome as compared with the control group. This study aimed to gain more insight into the characteristics of these patients. METHODS In PASS, 2,550 patients were randomly assigned to preventive antibiotic treatment with ceftriaxone or standard care. In current post-hoc analysis, 836 patients who received IVT were included. Primary outcome included functional status on the modified Rankin Scale, analyzed with adjusted ordinal regression. Secondary outcomes included infection rate and symptomatic intracerebral hemorrhage (sICH) rate. RESULTS For all patients in PASS, the p value for the interaction between IVT and preventive ceftriaxone regarding functional outcome was 0.03. Of the 836 IVT-treated patients, 437 were administered ceftriaxone and 399 were allocated to the control group. Baseline characteristics were similar. In the IVT subgroup, preventive ceftriaxone was associated with a significant reduction in unfavorable outcome (adjusted common OR 0.77; 95% CI 0.61-0.99; p = 0.04). Mortality at 3 months was similar (OR 0.75; 95% CI 0.48-1.18). Preventive ceftriaxone was associated with a reduction in infections (OR 0.43; 95% CI 0.28-0.66), and a trend towards an increased risk for sICH (OR 3.09; 95% CI 0.85-11.31). Timing of ceftriaxone administration did not influence the outcome (aOR 1.00; 95% CI 0.98-1.03; p = 0.85). CONCLUSIONS According to the post-hoc analysis of PASS, preventive ceftriaxone may improve the functional outcome in IVT-treated patients with acute stroke, despite a trend towards an increased rate of post-IVT-sICH.
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Affiliation(s)
- Jan-Dirk Vermeij
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
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Bustamante A, García-Berrocoso T, Rodriguez N, Llombart V, Ribó M, Molina C, Montaner J. Ischemic stroke outcome: A review of the influence of post-stroke complications within the different scenarios of stroke care. Eur J Intern Med 2016; 29:9-21. [PMID: 26723523 DOI: 10.1016/j.ejim.2015.11.030] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 09/28/2015] [Accepted: 11/30/2015] [Indexed: 12/21/2022]
Abstract
Stroke remains one of the main causes of death and disability worldwide. The challenge of predicting stroke outcome has been traditionally assessed from a general point of view, where baseline non-modifiable factors such as age or stroke severity are considered the most relevant factors. However, after stroke occurrence, some specific complications such as hemorrhagic transformations or post stroke infections, which lead to a poor outcome, could be developed. An early prediction or identification of these circumstances, based on predictive models including clinical information, could be useful for physicians to individualize and improve stroke care. Furthermore, the addition of biological information such as blood biomarkers or genetic polymorphisms over these predictive models could improve their prognostic value. In this review, we focus on describing the different post-stroke complications that have an impact in short and long-term outcome across different time points in its natural history and on the clinical-biological information that might be useful in their prediction.
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Affiliation(s)
- Alejandro Bustamante
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain
| | - Teresa García-Berrocoso
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain
| | - Noelia Rodriguez
- Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Victor Llombart
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain
| | - Marc Ribó
- Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Carlos Molina
- Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain; Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
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23
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Rae N, Chalmers JD. Antibiotic prophylaxis is ineffective in preventing pneumonia post-stroke. J R Coll Physicians Edinb 2015; 45:276-7. [DOI: 10.4997/jrcpe.2015.405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- N Rae
- Specialty Registrar in Infectious Diseases and General Medicine, Infection and Immunodeficiency Unit, Ninewells Hospital, Dundee, UK
| | - JD Chalmers
- Senior Clinical Lecturer and Honorary Consultant Physician in Respiratory Medicine, School of Medicine, University of Dundee, Dundee, UK
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Kalra L, Irshad S, Hodsoll J, Simpson M, Gulliford M, Smithard D, Patel A, Rebollo-Mesa I. Prophylactic antibiotics after acute stroke for reducing pneumonia in patients with dysphagia (STROKE-INF): a prospective, cluster-randomised, open-label, masked endpoint, controlled clinical trial. Lancet 2015; 386:1835-44. [PMID: 26343840 DOI: 10.1016/s0140-6736(15)00126-9] [Citation(s) in RCA: 176] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Post-stroke pneumonia is associated with increased mortality and poor functional outcomes. This study assessed the effectiveness of antibiotic prophylaxis for reducing pneumonia in patients with dysphagia after acute stroke. METHODS We did a prospective, multicentre, cluster-randomised, open-label controlled trial with masked endpoint assessment of patients older than 18 years with dysphagia after new stroke recruited from 48 stroke units in the UK, accredited and included in the UK National Stroke Audit. We excluded patients with contraindications to antibiotics, pre-existing dysphagia, or known infections, or who were not expected to survive beyond 14 days. We randomly assigned the units (1:1) by computer to give either prophylactic antibiotics for 7 days plus standard stroke unit care or standard stroke unit care only to patients clustered in the units within 48 h of stroke onset. We did the randomisation with minimisation to stratify for number of admissions and access to specialist care. Patient and staff who did the assessments and analyses were masked to stroke unit allocation. The primary outcome was post-stroke pneumonia in the first 14 days, assessed with both a criteria-based, hierarchical algorithm and by physician diagnosis in the intention-to-treat population. Safety was also analysed by intention to treat. This trial is closed to new participants and is registered with isrctn.com, number ISRCTN37118456. FINDINGS Between April 21, 2008, and May 17, 2014, we randomly assigned 48 stroke units (and 1224 patients clustered within the units) to the two treatment groups: 24 to antibiotics and 24 to standard care alone (control). 11 units and seven patients withdrew after randomisation before 14 days, leaving 1217 patients in 37 units for the intention-to-treat analysis (615 patients in the antibiotics group, 602 in control). Prophylactic antibiotics did not affect the incidence of algorithm-defined post-stroke pneumonia (71 [13%] of 564 patients in antibiotics group vs 52 [10%] of 524 in control group; marginal adjusted odds ratio [OR] 1·21 [95% CI 0·71-2·08], p=0·489, intraclass correlation coefficient [ICC] 0·06 [95% CI 0·02-0·17]. Algorithm-defined post-stroke pneumonia could not be established in 129 (10%) patients because of missing data. Additionally, we noted no differences in physician-diagnosed post-stroke pneumonia between groups (101 [16%] of 615 patients vs 91 [15%] of 602, adjusted OR 1·01 [95% CI 0·61-1·68], p=0·957, ICC 0·08 [95% CI 0·03-0·21]). The most common adverse events were infections unrelated to post-stroke pneumonia (mainly urinary tract infections), which were less frequent in the antibiotics group (22 [4%] of 615 vs 45 [7%] of 602; OR 0·55 [0·32-0·92], p=0·02). Diarrhoea positive for Clostridium difficile occurred in two patients (<1%) in the antibiotics group and four (<1%) in the control group, and meticillin-resistant Staphylococcus aureus colonisation occurred in 11 patients (2%) in the antibiotics group and 14 (2%) in the control group. INTERPRETATION Antibiotic prophylaxis cannot be recommended for prevention of post-stroke pneumonia in patients with dysphagia after stroke managed in stroke units. FUNDING UK National Institute for Health Research.
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Affiliation(s)
- Lalit Kalra
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neurosciences, King's College London, London, UK.
| | - Saddif Irshad
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neurosciences, King's College London, London, UK
| | - John Hodsoll
- King's Clinical Trials Unit, Biostatistics Department, Institute of Psychiatry, Psychology and Neurosciences, King's College London, London, UK; UK and NIHR Biomedical Research Centre for Mental Health, South London and Maudsley NHS Foundation Trust and Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Matthew Simpson
- UK Joint Clinical Trials Office, The King's Health Partners, Guy's and St Thomas' Hospital, London, UK
| | - Martin Gulliford
- Division of Health and Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | | | - Anita Patel
- Centre for the Economics of Mental and Physical Health, Institute of Psychiatry, Psychology and Neurosciences, King's College London, London, UK
| | - Irene Rebollo-Mesa
- King's Clinical Trials Unit, Biostatistics Department, Institute of Psychiatry, Psychology and Neurosciences, King's College London, London, UK
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Affiliation(s)
- Andreas Meisel
- NeuroCure Clinical Research Center, Center for Stroke Research Berlin, Department of Neurology, Charité Universitaetsmedizin Berlin, D-10117 Berlin, Germany.
| | - Craig J Smith
- Centre for Stroke and Vascular Research, Salford Royal Hospital NHS Foundation Trust, Salford, UK
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Fan H, Song F. An assessment of randomized controlled trials (RCTs) for non-communicable diseases (NCDs): more and higher quality research is required in less developed countries. Sci Rep 2015; 5:13221. [PMID: 26272174 PMCID: PMC4642521 DOI: 10.1038/srep13221] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 07/21/2015] [Indexed: 12/21/2022] Open
Abstract
Research is crucial to implement evidence-based health interventions for control of non-communicable diseases (NCDs). This study aims to assess main features of randomized controlled trials (RCTs) for control of NCDs, and to identify gaps in clinical research on NCDs between high-income and less developed countries. The study included 1177 RCTs in 82 Cochrane Systematic reviews (CSRs) and evaluated interventions for adults with hypertension, diabetes, stroke, or heart diseases. Multivariate logistic regression analyses were conducted to explore factors associated with risk of bias in included RCTs. We found that 78.2% of RCTs of interventions for major NCDs recruited patients in high-income countries. The number of RCTs included in the CSRs was increasing over time, and the increasing speed was more noticeable for RCTs conducted in middle-income countries. RCTs conducted in less developed countries tended to be more recently published, less likely to be published in English, with smaller sample sizes, and at a higher risk of bias. In conclusion, there is still a lack of research evidence for control of NCDs in less developed countries. To brace for rising NCDs and avoid waste of scarce research resources, not only more but also higher quality clinical trials are required in low-and-middle-income countries.
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Affiliation(s)
- Hong Fan
- Department of Social Medicine and Health Education, School of Public Health, Nanjing Medical University, Nanjing, P.R. China
| | - Fujian Song
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, U.K
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27
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Westendorp WF, Vermeij JD, Zock E, Hooijenga IJ, Kruyt ND, Bosboom HJLW, Kwa VIH, Weisfelt M, Remmers MJM, ten Houten R, Schreuder AHCMT, Vermeer SE, van Dijk EJ, Dippel DWJ, Dijkgraaf MGW, Spanjaard L, Vermeulen M, van der Poll T, Prins JM, Vermeij FH, Roos YBWEM, Kleyweg RP, Kerkhoff H, Brouwer MC, Zwinderman AH, van de Beek D, Nederkoorn PJ. The Preventive Antibiotics in Stroke Study (PASS): a pragmatic randomised open-label masked endpoint clinical trial. Lancet 2015; 385:1519-26. [PMID: 25612858 DOI: 10.1016/s0140-6736(14)62456-9] [Citation(s) in RCA: 216] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND In adults with acute stroke, infections occur commonly and are associated with an unfavourable functional outcome. In the Preventive Antibiotics in Stroke Study (PASS) we aimed to establish whether or not preventive antimicrobial therapy with a third-generation cephalosporin, ceftriaxone, improves functional outcome in patients with acute stroke. METHODS In this multicentre, randomised, open-label trial with masked endpoint assessment, patients with acute stroke were randomly assigned to intravenous ceftriaxone at a dose of 2 g, given every 24 h intravenously for 4 days, in addition to stroke unit care, or standard stroke unit care without preventive antimicrobial therapy; assignments were made within 24 h after symptom onset. The primary endpoint was functional outcome at 3 months, defined according to the modified Rankin Scale and analysed by intention to treat. The primary analysis was by ordinal regression of the primary outcome. Secondary outcomes included death, infection rates, antimicrobial use, and length of hospital stay. Participants and caregivers were aware of treatment allocation but assessors of outcome were masked to group assignment. This trial is registered with controlled-trials.com, number ISRCTN66140176. FINDINGS Between July 6, 2010, and March 23, 2014, a total of 2550 patients from 30 sites in the Netherlands, including academic and non-academic medical centres, were randomly assigned to the two treatment groups: 1275 patients to ceftriaxone and 1275 patients to standard treatment (control group). 12 patients (seven in the ceftriaxone group and five in the control group) withdrew consent immediately after randomisation, leaving 2538 patients available for the intention-to-treat-analysis (1268 in the ceftriaxone group and 1270 in the control group). 2514 (99%) of 2538 patients (1257 in each group) completed 3-month follow-up. Preventive ceftriaxone did not affect the distribution of functional outcome scores on the modified Rankin Scale at 3 months (adjusted common odds ratio 0·95 [95% CI 0·82-1·09], p=0·46). Preventive ceftriaxone did not result in an increased occurrence of adverse events. Overgrowth infection with Clostridium difficile occurred in two patients (<1%) in the ceftriaxone group and none in the control group. INTERPRETATION Preventive ceftriaxone does not improve functional outcome at 3 months in adults with acute stroke. The results of our trial do not support the use of preventive antibiotics in adults with acute stroke. FUNDING Netherlands Organization for Health Research and Development, Netherlands Heart Foundation, and the European Research Council.
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Affiliation(s)
- Willeke F Westendorp
- Department of Neurology, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Jan-Dirk Vermeij
- Department of Neurology, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Elles Zock
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Imke J Hooijenga
- Department of Neurology, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Slotervaart Hospital, Amsterdam, Netherlands
| | - Hans J L W Bosboom
- Department of Neurology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Vincent I H Kwa
- Department of Neurology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Martijn Weisfelt
- Department of Neurology, Kennemer Gasthuis, Haarlem, Netherlands
| | | | - Robert ten Houten
- Department of Neurology, Medisch Centrum Alkmaar, Alkmaar, Netherlands
| | | | - Sarah E Vermeer
- Department of Neurology, Rijnstate Hospital, Arnhem, Netherlands
| | - Ewout J van Dijk
- Department of Neurology, Radboudumc, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Marcel G W Dijkgraaf
- Clinical Research Unit, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Lodewijk Spanjaard
- Department of Medical Microbiology, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Marinus Vermeulen
- Department of Neurology, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Tom van der Poll
- Infectious Diseases, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Jan M Prins
- Infectious Diseases, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | | | - Yvo B W E M Roos
- Department of Neurology, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Ruud P Kleyweg
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Matthijs C Brouwer
- Department of Neurology, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology and Biostatistics, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Diederik van de Beek
- Department of Neurology, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.
| | - Paul J Nederkoorn
- Department of Neurology, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
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Worthmann H, Tryc AB, Dirks M, Schuppner R, Brand K, Klawonn F, Lichtinghagen R, Weissenborn K. Lipopolysaccharide binding protein, interleukin-10, interleukin-6 and C-reactive protein blood levels in acute ischemic stroke patients with post-stroke infection. J Neuroinflammation 2015; 12:13. [PMID: 25613713 PMCID: PMC4307994 DOI: 10.1186/s12974-014-0231-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 12/21/2014] [Indexed: 11/10/2022] Open
Abstract
Background Ischemic stroke patients are prone to infection by stroke-induced immunodepression. We hypothesized that levels of lipopolysaccharide binding protein (LBP), interleukin-10 (IL-10), IL-6 and C-reactive protein (CRP) are early predictors for the development of stroke-associated infection. Methods Fifty-six patients with ischemic stroke (n = 51) and transient ischemic attack (TIA) (n = 5) who presented within 6 hours after symptom onset and who were free of detectable infection on admission were included in the study. Of these, 20 developed early infections during the first week. Blood samples were taken at 6, 12, and 24 hours and at 3 and 7 days after stroke onset. Levels of LBP, Il-10, IL-6 and CRP, as well as S100B, were measured as markers of inflammation and brain damage by commercially available immunometric tests. Results In the univariate analysis, levels of LBP, IL-10, IL-6 and CRP significantly differed between patients who developed an infection and those who did not. In the binary logistic regression analysis, which was adjusted for National Institutes of Health Stroke Scale (NIHSS) on admission, stroke subtype and S100B peak levels, as indicator of the extent of brain damage, IL-10 at 6 hours, CRP at 6 hours and NIHSS on admission were identified as independent predictors of infection (IL-10: P = 0.009; CRP: P = 0.018; NIHSS: P = 0.041). The area under the curve (AUC) of the receiver operating characteristic (ROC) curves in relation to the dichotomized status of the infection (infection versus no infection) was 0.74 (95% confidence interval: 0.59 to 0.88) for CRP at 6 hours, 0.76 (0.61 to 0.9) for IL-10 at 6 hours, 0.83 (0.71 to 0.94) for NIHSS on admission and 0.94 (0.88 to 1) for the combination of CRP, IL-10 and NIHSS. In a subanalysis, 16 patients with early infections were matched with 16 patients without infection according to S100B peak levels. Here, the temporal pattern of LBP, IL-10, IL-6 and CRP significantly differed between the patient groups. Conclusions Our data show that blood levels of inflammation markers may be used as early predictors of stroke-associated infection. We propose prospective studies to investigate if the calculated cut-offs of CRP, IL-10 and NIHSS might help to identify patients who should receive early preventive antibiotic treatment.
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Affiliation(s)
- Hans Worthmann
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30623, Hannover, Germany.
| | - Anita B Tryc
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30623, Hannover, Germany.
| | - Meike Dirks
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30623, Hannover, Germany.
| | - Ramona Schuppner
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30623, Hannover, Germany.
| | - Korbinian Brand
- Department of Clinical Chemistry, Hannover Medical School, Carl-Neuberg-Str. 1, 30623, Hannover, Germany.
| | - Frank Klawonn
- Department of Computer Science, Ostfalia University of Applied Sciences, Am Exer 2, 38302, Wolfenbuettel, Germany. .,Biostatistics, Helmholtz Centre for Infection Research, Inhoffenstr. 7, 38124, Braunschweig, Germany.
| | - Ralf Lichtinghagen
- Department of Clinical Chemistry, Hannover Medical School, Carl-Neuberg-Str. 1, 30623, Hannover, Germany.
| | - Karin Weissenborn
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30623, Hannover, Germany. .,Center for Systems Neuroscience (ZSN), Buenteweg 2, 30559, Hannover, Germany.
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Friedant AJ, Gouse BM, Boehme AK, Siegler JE, Albright KC, Monlezun DJ, George AJ, Beasley TM, Martin-Schild S. A simple prediction score for developing a hospital-acquired infection after acute ischemic stroke. J Stroke Cerebrovasc Dis 2015; 24:680-6. [PMID: 25601173 DOI: 10.1016/j.jstrokecerebrovasdis.2014.11.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 11/14/2014] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Hospital-acquired infections (HAIs) are a major cause of morbidity and mortality in acute ischemic stroke patients. Although prior scoring systems have been developed to predict pneumonia in ischemic stroke patients, these scores were not designed to predict other infections. We sought to develop a simple scoring system for any HAI. METHODS Patients admitted to our stroke center (July 2008-June 2012) were retrospectively assessed. Patients were excluded if they had an in-hospital stroke, unknown time from symptom onset, or delay from symptom onset to hospital arrival greater than 48 hours. Infections were diagnosed via clinical, laboratory, and imaging modalities using standard definitions. A scoring system was created to predict infections based on baseline patient characteristics. RESULTS Of 568 patients, 84 (14.8%) developed an infection during their stays. Patients who developed infection were older (73 versus 64, P < .0001), more frequently diabetic (43.9% versus 29.1%, P = .0077), and had more severe strokes on admission (National Institutes of Health Stroke Scale [NIHSS] score 12 versus 5, P < .0001). Ranging from 0 to 7, the overall infection score consists of age 70 years or more (1 point), history of diabetes (1 point), and NIHSS score (0-4 conferred 0 points, 5-15 conferred 3 points, >15 conferred 5 points). Patients with an infection score of 4 or more were at 5 times greater odds of developing an infection (odds ratio, 5.67; 95% confidence interval, 3.28-9.81; P < .0001). CONCLUSION In our sample, clinical, laboratory, and imaging information available at admission identified patients at risk for infections during their acute hospitalizations. If validated in other populations, this score could assist providers in predicting infections after ischemic stroke.
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Affiliation(s)
- Adam J Friedant
- Stroke Program, Department of Neurology, Tulane University Hospital, New Orleans, LA
| | - Brittany M Gouse
- Stroke Program, Department of Neurology, Tulane University Hospital, New Orleans, LA
| | - Amelia K Boehme
- Gertrude H. Sergievsky Center, Department of Neurology, Columbia University, New York, NY; Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - James E Siegler
- Stroke Program, Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Karen C Albright
- Department of Epidemiology, School of Public Health; Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (COERE), Division of Preventive Medicine; Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities (CERED) Minority Health & Health Disparities Research Center (MHRC)
| | - Dominique J Monlezun
- Stroke Program, Department of Neurology, Tulane University Hospital, New Orleans, LA
| | - Alexander J George
- Stroke Program, Department of Neurology, Tulane University Hospital, New Orleans, LA
| | - Timothy Mark Beasley
- Section on Statistical Genetics, Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Sheryl Martin-Schild
- Stroke Program, Department of Neurology, Tulane University Hospital, New Orleans, LA.
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Li Y, Song B, Fang H, Gao Y, Zhao L, Xu Y. External validation of the A2DS2 score to predict stroke-associated pneumonia in a Chinese population: a prospective cohort study. PLoS One 2014; 9:e109665. [PMID: 25299226 PMCID: PMC4192306 DOI: 10.1371/journal.pone.0109665] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Accepted: 09/02/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND PURPOSE The A2DS2 score was recently developed from the Berlin Stroke Registry for predicting in-hospital pneumonia after acute ischemic stroke and performed well in an external validation in the North-west Germany Stroke Registry. It could be a useful tool for risk stratification in clinical practice or stroke trials. We aimed to prospectively validate the predictive value of A2DS2 score in a Chinese stroke population. METHODS The prognostic model was used to predict stroke-associated pneumonia (SAP) from Henan Province Stroke Registry (HNSR) in which data were prospectively collected. The receiver-operating characteristic curves were plotted, and the C statistics were calculated to assess the discrimination ability. The Hosmer-Lemeshow goodness-of-fit test and the plot of observed versus predicted SAP risk were used to assess model calibration. RESULTS Among 1142 eligible patients, the overall in-hospital SAP was 18.8%, which ranged from 9.0% in patients with lower A2DS2 scores (0-4) to 65.0% in those with higher scores of 5 to 10 (P for trend <0.001). The C statistic was 0.836 (95% confidence interval, 0.803-0.868) through the A2DS2 score, suggesting excellent discrimination in the HNSR. The A2DS2 score also showed excellent calibration (Cox and Snell R2 = 0.243) in the external validation sample from the HNSR. CONCLUSIONS The A2DS2 score could reliably predict in-hospital SAP in Chinese stroke patients. It might be helpful for the assessment of increased risk monitoring and prophylactic treatment in identified high-risk patients for SAP in clinical routine.
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Affiliation(s)
- Yapeng Li
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Bo Song
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Hui Fang
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Yuan Gao
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Lu Zhao
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Yuming Xu
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
- * E-mail:
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Westendorp WF, Vermeij JD, Dippel DWJ, Dijkgraaf MGW, van der Poll T, Prins JM, Vermeij FH, Roos YBWEM, Brouwer MC, Zwinderman AH, van de Beek D, Nederkoorn PJ. Update of the Preventive Antibiotics in Stroke Study (PASS): statistical analysis plan. Trials 2014; 15:382. [PMID: 25269598 PMCID: PMC4195873 DOI: 10.1186/1745-6215-15-382] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 09/19/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Infections occur in 30% of stroke patients and are associated with unfavorable outcomes. Preventive antibiotic therapy lowers the infection rate after stroke, but the effect of preventive antibiotic treatment on functional outcome in patients with stroke is unknown. The PASS is a multicenter, prospective, phase three, randomized, open-label, blinded end-point (PROBE) trial of preventive antibiotic therapy in acute stroke. Patients are randomly assigned to either ceftriaxone at a dose of 2 g, given every 24 h intravenously for 4 days, in addition to standard stroke-unit care, or standard stroke-unit care without preventive antibiotic therapy. The aim of this study is to assess whether preventive antibiotic treatment improves functional outcome at 3 months by preventing infections. This paper presents in detail the statistical analysis plan (SAP) of the Preventive Antibiotics in Stroke Study (PASS) and was submitted while the investigators were still blinded for all outcomes. RESULTS The primary outcome is the score on the modified Rankin Scale (mRS), assessed by ordinal logistic regression analysis according to a proportional odds model. Secondary analysis of the primary outcome is the score on the mRS dichotomized as a favorable outcome (mRS 0 to 2) versus unfavorable outcome (mRS 3 to 6). Secondary outcome measures are death rate at discharge and 3 months, infection rate during hospital admission, length of hospital admission, volume of post-stroke care, use of antibiotics during hospital stay, quality-adjusted life years and costs. Complications of treatment, serious adverse events (SAEs) and suspected unexpected serious adverse reactions (SUSARs) are reported as safety outcomes. CONCLUSIONS The data from PASS will establish whether preventive antibiotic therapy in acute stroke improves functional outcome by preventing infection and will be analyzed according to this pre-specified SAP. TRIAL REGISTRATION Current controlled trials; ISRCTN66140176. Date of registration: 6 April 2010.
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Affiliation(s)
- Willeke F Westendorp
- />Department of Neurology, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam, the Netherlands
| | - Jan-Dirk Vermeij
- />Department of Neurology, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam, the Netherlands
| | - Diederik W J Dippel
- />Department of Neurology, Erasmus MC University Medical Center, P.O. Box Postbus 2040, 3000 CA Rotterdam, the Netherlands
| | - Marcel G W Dijkgraaf
- />Clinical Research Unit (CRU), Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam, the Netherlands
| | - Tom van der Poll
- />Department of Neurology, Center of Infection and Immunity (CINIMA), Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam, the Netherlands
- />Department of Infectious Diseases, Academic Medical Center, P.O Box 22660, 1100 DD Amsterdam, the Netherlands
| | - Jan M Prins
- />Department of Neurology, Center of Infection and Immunity (CINIMA), Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam, the Netherlands
- />Department of Infectious Diseases, Academic Medical Center, P.O Box 22660, 1100 DD Amsterdam, the Netherlands
| | - Frederique H Vermeij
- />Department of Neurology, Sint Franciscus Gasthuis, P.O. Box 10900, 3004 BA Rotterdam, the Netherlands
| | - Yvo B W E M Roos
- />Department of Neurology, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam, the Netherlands
| | - Matthijs C Brouwer
- />Department of Neurology, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam, the Netherlands
- />Department of Neurology, Center of Infection and Immunity (CINIMA), Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam, the Netherlands
| | - Aeilko H Zwinderman
- />Department of Clinical Epidemiology Biostatistics and Bioinformatics, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam, the Netherlands
| | - Diederik van de Beek
- />Department of Neurology, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam, the Netherlands
- />Department of Neurology, Center of Infection and Immunity (CINIMA), Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam, the Netherlands
| | - Paul J Nederkoorn
- />Department of Neurology, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam, the Netherlands
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Update on the Preventive Antibiotics in Stroke Study (PASS): a randomised controlled phase 3 clinical trial. Trials 2014; 15:133. [PMID: 24750904 PMCID: PMC4000143 DOI: 10.1186/1745-6215-15-133] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 04/02/2014] [Indexed: 11/10/2022] Open
Abstract
Background Stroke is a leading cause of death worldwide. Infections after stroke occur in 30% of stroke patients and are strongly associated with unfavourable outcome. Preventive antibiotic therapy lowers infection rate in patients after stroke, however, the effect of preventive antibiotic treatment on functional outcome after stroke has not yet been investigated.The Preventive Antibiotics in Stroke Study (PASS) is an ongoing, multicentre, prospective, randomised, open-label, blinded end point trial of preventive antibiotic therapy in acute stroke. Patients are randomly assigned to either ceftriaxone at a dose of 2 g, given every 24 hours intravenously for four-days, in addition to stroke-unit care, or standard stroke-unit care without preventive antibiotic therapy. Aim of the study is to assess whether preventive antibiotic treatment improves functional outcome at three months by preventing infections. Results To date, 2,470 patients have been included in PASS. Median stroke severity of the first 2,133 patients (second interim analysis) is 5 (IQR 3 to 9) on the National Institutes of Health Stroke Scale (NIHSS). Due to the PROBE design, no outcome data are available yet. In the initial trial protocol we proposed a dichotomisation of the mRS as primary analysis of outcome and ordinal regression analysis as secondary analysis of primary outcome, requiring a sample size of 3,200 patients. However, ordinal analysis of outcome data is becoming increasingly more common in acute stroke trials, as it increases statistical power. For PASS, funding is insufficient for inclusion of 3,200 patients with the overall inclusion rate of 15 patients per week. Therefore we change the analysis of our primary outcome from dichotomisation to ordinal regression analysis on the mRS. Power analysis showed that with similar assumptions 2,550 patients are needed using ordinal regression analysis. We expect to complete follow-up in June 2014. A full statistical analysis plan will be submitted for publication before treatment allocation will be unblinded. Conclusion The data from PASS will establish whether preventive antibiotic therapy in acute stroke improves functional outcome by preventing infection. In this update, we changed our primary outcome analysis from dichotomisation to ordinal regression analysis. Trial registration Current controlled trials; ISRCTN66140176. Date of registration: 6 April 2010.
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Kulnik ST, Rafferty GF, Birring SS, Moxham J, Kalra L. A pilot study of respiratory muscle training to improve cough effectiveness and reduce the incidence of pneumonia in acute stroke: study protocol for a randomized controlled trial. Trials 2014; 15:123. [PMID: 24725276 PMCID: PMC4021694 DOI: 10.1186/1745-6215-15-123] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 03/28/2014] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND After stroke, pneumonia is a relevant medical complication that can be precipitated by aspiration of saliva, liquids, or solid food. Swallowing difficulty and aspiration occur in a significant proportion of stroke survivors. Cough, an important mechanism protecting the lungs from inhaled materials, can be impaired in stroke survivors, and the likely cause for this impairment is central weakness of the respiratory musculature. Thus, respiratory muscle training in acute stroke may be useful in the recovery of respiratory muscle and cough function, and may thereby reduce the risk of pneumonia. The present study is a pilot study, aimed at investigating the validity and feasibility of this approach by exploring effect size, safety, and patient acceptability of the intervention. METHODS/DESIGN Adults with moderate to severe stroke impairment (National Institutes of Health Stroke Scale (NIHSS) score 5 to 25 at the time of admission) are recruited within 2 weeks of stroke onset. Participants must be able to perform voluntary respiratory maneuvers. Excluded are patients with increased intracranial pressure, uncontrolled hypertension, neuromuscular conditions other than stroke, medical history of asthma or chronic obstructive pulmonary disease, and recent cardiac events. Participants are randomized to receive inspiratory, expiratory, or sham respiratory training over a 4-week period, by using commercially available threshold resistance devices. Participants and caregivers, but not study investigators, are blind to treatment allocation. All participants receive medical care and stroke rehabilitation according to the usual standard of care. The following assessments are conducted at baseline, 4 weeks, and 12 weeks: Voluntary and reflex cough flow measurements, forced spirometry, respiratory muscle strength tests, incidence of pneumonia, assessments of safety parameters, and self-reported activity of daily living. The primary outcome is peak expiratory cough flow of voluntary cough, a parameter indicating the effectiveness of cough. Secondary outcomes are incidence of pneumonia, peak expiratory cough flow of reflex cough, and maximum inspiratory and expiratory mouth pressures. DISCUSSION Various novel pharmacologic and nonpharmacologic approaches for preventing stroke-associated pneumonia are currently being researched. This study investigates a novel strategy based on an exercise intervention for cough rehabilitation. TRIAL REGISTRATION Current Controlled Trials ISRCTN40298220.
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Affiliation(s)
- Stefan Tino Kulnik
- Stroke Research Team, Department of Clinical Neuroscience, Institute of Psychiatry, King’s College London, PO Box 41, Denmark Hill, London SE5 8AF, UK
| | - Gerrard Francis Rafferty
- Department of Respiratory Medicine and Allergy, School of Medicine, King’s College London, Chest Unit, Cheyne Wing, King’s College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Surinder S Birring
- Division of Asthma, Allergy & Lung Biology, School of Medicine, King’s College London, Chest Unit, Cheyne Wing, King’s College Hospital, Denmark Hill, London SE5 9RS, UK
| | - John Moxham
- Department of Respiratory Medicine and Allergy, King’s Health Partners, Chest Unit, Cheyne Wing, King’s College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Lalit Kalra
- Stroke Research Team, Department of Clinical Neuroscience, Institute of Psychiatry, King’s College London, PO Box 41, Denmark Hill, London SE5 8AF, UK
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Inpatient rehabilitation centers and concern for increasing volume of ischemic stroke patients requiring rehabilitation. South Med J 2014; 106:693-6. [PMID: 24305530 DOI: 10.1097/smj.0000000000000036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To determine whether prolonged length of stay (pLOS) in ischemic stroke is related to delays in discharge disposition arrangement. METHODS We designed a retrospective study to compare patients with acute ischemic stroke who experienced pLOS to those who did not experience pLOS. Patients who have had acute ischemic stroke between July 2008 and December 2010 were included unless they arrived >48 hours after time last seen normal, had an unknown last seen normal, or experienced an in-hospital stroke. pLOS was defined in our prospective stroke registry (before the generation of this research question) as hospitalization extended for ≥ 24 hours more than necessary to determine neurologic stability and next level of care/disposition for a given patient. We characterized the frequency of each cause of pLOS and further investigated the destinations that were more frequently associated with pLOS among patients with delay resulting from arranging discharge disposition. RESULTS Of the 274 patients included, 106 (31.9%) had pLOS. Reasons for pLOS were discharge disposition (48.1%), non-neurologic medical complications (36.8%), delays in imaging studies (20.8%), awaiting procedure (10.4%), and neurologic complications (9.4%). Among patients with pLOS caused by delayed disposition, more than half were awaiting placement in an inpatient rehabilitation facility. CONCLUSIONS For the majority of our patients, pLOS was caused by acquired medical complications and delayed disposition, most commonly inpatient rehabilitation. Further efforts are needed to prevent complications and further investigation is necessary to identify the factors that may contribute to delayed discharge to inpatient rehabilitation facilities, which may include delayed planning or heightened scrutiny of insurance companies regarding their beneficiaries.
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Boehme AK, Kumar AD, Dorsey AM, Siegler JE, Aswani MS, Lyerly MJ, Monlezun DJ, George AJ, Albright KC, Beasley TM, Martin-Schild S. Infections present on admission compared with hospital-acquired infections in acute ischemic stroke patients. J Stroke Cerebrovasc Dis 2013; 22:e582-9. [PMID: 23954599 DOI: 10.1016/j.jstrokecerebrovasdis.2013.07.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 07/04/2013] [Accepted: 07/08/2013] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND To date, few studies have assessed the influence of infections present on admission (POA) compared with hospital-acquired infections (HAIs) on neurologic deterioration (ND) and other outcome measures in acute ischemic stroke (AIS). METHODS Patients admitted with AIS to our stroke center (July 2010 to December 2010) were retrospectively assessed. The following infections were assessed: urinary tract infection, pneumonia, and bacteremia. Additional chart review was performed to determine whether the infection was POA or HAI. We assessed the relationship between infections in ischemic stroke patients and several outcome measures including ND and poor functional outcome. A mediation analysis was performed to assess the indirect effects of HAI, ND, and poor functional outcome. RESULTS Of the 334 patients included in this study, 77 had any type of infection (23 POA). After adjusting for age, National Institutes of Health Stroke Scale at baseline, glucose on admission, and intravenous tissue plasminogen activator, HAI remained a significant predictor of ND (odds ratio [OR]=8.8, 95% confidence interval [CI]: 4.2-18.7, P<.0001) and poor functional outcome (OR=41.7, 95% CI: 5.2-337.9, P=.005), whereas infections POA were no longer associated with ND or poor functional outcome. In an adjusted analysis, we found that 57% of the effect from HAI infections on poor functional outcome is because of mediation through ND (P<.0001). CONCLUSIONS Our data suggests that HAI in AIS patients increases the odds of experiencing ND and subsequently increases the odds of being discharged with significant disability. This mediated effect suggests a preventable cause of ND that can thereby decrease the odds of poor functional outcomes after an AIS.
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Affiliation(s)
- Amelia K Boehme
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Hannawi Y, Hannawi B, Rao CPV, Suarez JI, Bershad EM. Stroke-associated pneumonia: major advances and obstacles. Cerebrovasc Dis 2013; 35:430-43. [PMID: 23735757 DOI: 10.1159/000350199] [Citation(s) in RCA: 231] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 02/14/2013] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Stroke-associated pneumonia (SAP) has been implicated in the morbidity, mortality and increased medical cost after acute ischemic stroke. The annual cost of SAP during hospitalization in the United States approaches USD 459 million. The incidence and prognosis of SAP among intensive care unit (ICU) patients have not been thoroughly investigated. We reviewed the pathophysiology, microbiology, incidence, risk factors, outcomes and prophylaxis of SAP with special attention to ICU studies. METHODS To determine the incidence, risk factors and prognosis of acute SAP, PubMed was searched using the terms 'pneumonia' AND 'neurology intensive unit' and the MeSH terms 'stroke' AND 'pneumonia'. Non-English literature, case reports and chronic SAP studies were excluded. Studies were classified into 5 categories according to the setting they were performed in: neurological intensive care units (NICUs), medical intensive care units (MICUs), stroke units, mixed studies combining more than one setting or when the settings were not specified and rehabilitation studies. RESULTS The incidences of SAP in the following settings were: NICUs 4.1-56.6%, MICUs 17-50%, stroke units 3.9-44%, mixed studies 3.9-23.8% and rehabilitation 3.2-11%. The majority of NICU and MICU studies were heterogeneous including different neurovascular diseases, which partly explains the wide range of SAP incidence. The higher incidence in the majority of ICU studies compared to stroke units or acute floor studies is likely explained by the presence of mechanical ventilation, higher stroke severity causing higher rates of aspiration and stroke-induced immunodepression among ICU patients. The short-term mortality of SAP was increased among the mixed and stroke unit studies ranging between 10.1 and 37.3%. SAP was associated with worse functional outcome in the majority of stroke unit and floor studies. Mortality was less consistent among NICU and MICU studies. This difference could be due to the heterogeneity of ICU studies and the effect of small sample size or other independent risk factors for mortality such as the larger neurological deficit, mechanical ventilation, and age, which may simultaneously increase the risk of SAP and mortality confounding the outcomes of SAP itself. The pathophysiology of SAP is likely explained by aspiration combined with stroke-induced immunodepression through complex humeral and neural pathways that include the hypothalamic-pituitary-adrenal axis, parasympathetic and sympathetic systems. CONCLUSIONS A unified definition of SAP, strict inclusion criteria, and the presence of a long-term follow-up need to be applied to the future prospective studies to better identify the incidence and prognosis of SAP, especially among ICU patients.
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Affiliation(s)
- Yousef Hannawi
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA. yousefhannawi @ yahoo.com
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van de Beek D. Long-term effect of infections after stroke. Nat Rev Neurol 2013; 9:126-7. [DOI: 10.1038/nrneurol.2013.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Yousuf S, Atif F, Sayeed I, Wang J, Stein DG. Post-stroke infections exacerbate ischemic brain injury in middle-aged rats: immunomodulation and neuroprotection by progesterone. Neuroscience 2012; 239:92-102. [PMID: 23079632 DOI: 10.1016/j.neuroscience.2012.10.017] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 09/26/2012] [Accepted: 10/05/2012] [Indexed: 01/22/2023]
Abstract
We investigated the effect of delayed, prolonged systemic inflammation on stroke outcomes and progesterone (P4) neuroprotection in middle-aged rats. After transient middle cerebral artery occlusion/reperfusion (MCAO) surgery, rats received P4 (8 or 16 mg/kg) or vehicle injections at 2h, 6h and every 24h until day 7 post-occlusion. At 24h post-injury systemic inflammation was induced by giving three doses of lipopolysaccharide (LPS; 50 μg/kg, at 4h intervals) to model post-stroke infections. We measured serum brain-derived neurotrophic factor (BDNF), pro-inflammatory cytokines, and behavioral parameters at multiple times. Serum BDNF levels decreased more in the vehicle+LPS group compared to vehicle-alone at 3 and 7 days post-injury (P<0.05). Vehicle-alone showed a significant increase in interleukin-1β, interleukin-6, and tumor necrosis factor alpha levels at different times following stroke and these levels were further elevated in the vehicle+LPS group. P4 at both doses produced a significant (P<0.05) decline in cytokine levels compared to vehicle and vehicle+LPS. P4 restored BDNF levels at 3 and 7 days post-stroke (P<0.05). Behavioral assessment (rotarod, grip strength, sensory neglect and locomotor activity tests) at 3, 5 and 7 days post-stroke revealed that the vehicle group had significant (P<0.05) deficits in all tests compared to intact controls, and performance was worse in the vehicle+LPS group. P4 at both doses produced significant functional improvement on all tests. Systemic inflammation did not show an additive effect on infarct volume but P4 at both doses showed significant infarct reduction. We suggest that post-stroke infection exacerbates stroke outcomes and P4 exerts neuroprotective/modulatory effects through its systemic anti-inflammatory and BDNF regulatory actions.
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Affiliation(s)
- S Yousuf
- Department of Emergency Medicine, Brain Research Laboratory, Emory University, Atlanta, GA 30322, USA
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Ulm L, Harms H, Ohlraun S, Reimnitz P, Meisel A. Impact of infections on long-term outcome after severe middle cerebral artery infarction. J Neurol Sci 2012; 319:15-7. [PMID: 22682764 DOI: 10.1016/j.jns.2012.05.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Revised: 04/19/2012] [Accepted: 05/21/2012] [Indexed: 10/28/2022]
Abstract
Post-stroke infections are the most important complications after acute stroke, accounting for almost 20% of in-hospital deaths and poor functional outcomes at discharge. Little is known about long-term effects of post-stroke infections on outcome. Here, we studied the impact of infections on long-term outcome in 64 patients which had suffered from severe middle cerebral artery infarction. Mean follow-up time in the survivors was 6.5 ± 0.9 years. Structured telephone interviews were performed to assess the patients' current functional outcome. Where re-contacting was not successful, vital status of the patients was requested at the registration office of Berlin. Multiple logistic regression analysis identified three independent risk factors associated with mortality: infections within the first 11 days after stroke, age>64 years, and female sex. Among surviving patients, functional outcome measured by Barthel Index was influenced by infections and immunocompetence measured by levels of monocytic HLA-DR expression on day 3 after stroke. In conclusion, the occurrence of post-stroke infections is the most important predictor of poor long-term outcome in this cohort of patients. Our observation warrants prospective trials on prevention or early treatment of post-stroke infections in order to improve long-term outcome after stroke.
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Affiliation(s)
- Lena Ulm
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
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Abstract
Recent clinical and experimental studies have highlighted a complex role for the immune system in the pathophysiological changes that occur after acute stroke. Sensors of the innate immune system such as Toll-like receptors, or effectors such as the lectin pathway of complement activation and innate immune cells, are activated by brain ischaemia and tissue damage, leading to amplification of the inflammatory cascade. Activation of the adaptive arm of the immune system, mediated by lymphocyte populations including T and B cells, regulatory T cells, and γδT cells, in response to stroke can lead to deleterious antigen-specific autoreactive responses but can also have cytoprotective effects. Increased incidence of infections is observed after acute stroke, and might result from activation of long-distance feedback loops between the CNS and peripheral immune organs, which are thought to play a part in stroke-induced immunodepression. Ongoing clinical trials are investigating whether the preventive use of antibiotics improves functional outcome after stroke. This Review discusses the multifaceted role of the immune system in the pathophysiology of acute stroke.
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